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Malaria initiative progresses

By Roger Bate

Washington Times

December 14, 2006

Commentary

Today the White House will host its first-ever summit on malaria. It will celebrate a major change in U.S. malaria control policy and should provide the president some much needed good publicity. It is too early to conclusively prove the efficacy of enacted policy changes. But there is no doubt the Global Health Bureau of the U.S. Agency for International Development, which is making the changes, is moving foreign assistance in the right direction.

This has been quite a year for U.S. foreign aid. On Jan. 19, Secretary of State Condoleezza Rice announced fundamental changes to U.S. foreign assistance, aligning USAID more closely with the State Department. Miss Rice declared that policies were being reoriented to "build and sustain democratic, well-governed states that will respond to the needs of their people and conduct themselves responsibly in the international system." Miss Rice had already overseen acceleration in foreign assistance funding, from about $10 billion in 2000 to more than $27 billion in 2006.

But access to basic health in poor countries, a robust proxy for development, remains very low. USAID has had little to show for its efforts. Though U.S. foreign health funding has increased from about $1.6 billion in 2001 to just more than $4 billion in 2006, USAID rarely measured its performance and has often been ineffectual, notably in malaria control.

Malaria, an entirely preventable and treatable disease, kills at least a million people yearly, mostly children under age 5 and pregnant women. Prompted by anti-malaria advocates, the U.S. Congress led a series of investigations into USAID's malaria control programs between September 2004 and January 2006. These hearings found almost no monitoring and evaluation of performance, no ability to account for spending with any meaningful precision, and the promotion of poor public health and clinical practices.

Contractors could decide what information to redact from contracts, so researchers could not ascertain how budgets were spent. Of the money accounted for, most went to general advice-giving programs and consultants seemingly incapable of building sustainable local capacity. Only about 8 percent of its $80 million fiscal 2004 budget was used to purchase actual lifesaving interventions, such as bed nets, insecticides or effective drugs.

Technical advice and training play a role in sustainable development, but the agency could provide almost no evidence that programs actually helped save lives, build sustainable local infrastructures, provide effective interventions or cooperate with other agencies. USAID's measurements focused almost entirely on inputs, such as the number of nets distributed, drugs purchased or health workers trained in a certain locale, rather than outcomes (improvements in health).

Sen. Tom Coburn, Oklahoma Republican, host of several of the key hearings exploring USAID's regrettable failings, once likened the new criticisms to bursts of "sunlight" shining on the malaria program. The Senate Subcommittee hearing in May 2005, coupled with persistently unfavorable coverage in the academic and popular press, marked a turning point for the Global Health Bureau.

Yet USAID worked with the Office of the President to change malaria practices. On June 30, 2005, President Bush launched the President's Malaria Initiative (PMI), a $1.2 billion initiative to halve malaria by 2010 in 15 countries. It initially funded Angola, Tanzania and Uganda for fiscal 2006, focusing on effective management, best practices, transparency and accountability.

This initiative did not apply to regular program funding for malaria control, so six months after PMI's inception and in his final days as USAID administrator, Andrew Natsios announced momentous and largely unprecedented reforms to USAID's malaria program. The agency promised to shut down all minor programs for malaria control that spent less than $1.5 million annually. This was a welcomed change, as USAID had previously spread funds too thinly. While half its fiscal 2005 budget was spread between 21 African country-level programs and 3 regional offices, more than two-thirds of its fiscal 2006 budget went to 17 African countries and one regional office.

USAID also promised to allocate nearly half of its budget to buying commodities, such as bed nets, insecticides and effective drugs. At the close of fiscal 2006, USAID's malaria program is achieving many of its targets.

One key problem remains. There appears to be no effort to disengage USAID from supporting large Beltway contractors, often with little competition in contracting. This is hard to square with USAID's stated commitment to build country capacity and foster sustainable development.

But this problem should not stop the White House celebrations today. Fewer children have malaria because of the President's Malaria Initiative and in this festive season, I for one, will drink to that.

Roger Bate is a resident fellow of the American Enterprise Institute of Public Policy Research.